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Labor: Overview of normal and abnormal progression

Authors: Robert M Ehsanipoor, MD, Andrew J Satin, MD, FACOG
Section Editor: Vincenzo Berghella, MD
Deputy Editor: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2022. | This topic last updated: May 02, 2022.

INTRODUCTION

Labor is defined as regular and painful uterine contractions that cause progressive dilation
and effacement of the cervix. The rate of cervical dilation becomes faster after the cervix is
completely effaced [1]. Normal labor results in descent and eventual expulsion of the fetus.
Parity affects this process: Parous patients who have had a previous vaginal birth have faster
labors than nulliparous patients.

Although determining whether labor is progressing normally is a key component of

intrapartum care, determining the time of labor onset, measuring its progress, and
evaluating the uterine, fetal, and pelvic factors that affect its course are an inexact science.
"Abnormal labor," "dystocia," and "failure to progress" are traditional but imprecise terms
that have been used to describe a labor pattern deviating from that observed in most
patients who have a spontaneous vaginal birth. These labor abnormalities are best
described as protraction disorders (ie, slower than normal progress) or arrest disorders (ie,
complete cessation of progress). By convention, an abnormally long active phase is usually
described as protracted, whereas an abnormally long latent phase or second stage is usually
described as prolonged.

Recognizing abnormal labor progression and initiating appropriate interventions are

important because it is associated with increased risks for operative delivery and maternal
and neonatal morbidity.

This topic will provide an overview of labor progress and discuss risk factors for abnormal
progression. Management of normal labor and delivery; diagnosis and management of
abnormalities of the latent phase, first stage, and second stage; and management of the
third stage are reviewed separately:
 ● (See "Labor and delivery: Management of the normal first stage".)
● (See "Labor: Diagnosis and management of the latent phase".)
● (See "Labor: Diagnosis and management of an abnormal first stage".)
● (See "Labor: Diagnosis and management of a prolonged second stage".)
● (See "Management of the third stage of labor: Prophylactic pharmacotherapy to
minimize hemorrhage" and "Retained placenta after vaginal birth".)

DEFINITIONS FOR THE STAGES AND PHASES OF LABOR

Interpreting labor progress depends on the stage and phase:

● First stage: The time from onset of labor to complete cervical dilation.

To document the onset of labor, patients are simply asked the time when they believe
labor began (ie, when contractions started to occur regularly every three to five
minutes for more than an hour). The time of complete dilation is when this finding is
first identified on physical examination.

It is impossible to determine the precise times of both the start of labor and complete
dilation since the normal uterus contracts intermittently and irregularly throughout
gestation, the initial regular contractions at the onset of labor are mild and infrequent,
initial cervical changes are subtle, and physical examination to document cervical
change is performed intermittently.

• Phases: The first stage consists of a latent phase and an active phase. The latent
phase is characterized by gradual cervical change, and the active phase is
characterized by more rapid cervical change.

The labor curve of parous patients may show an inflection point between the latent
and active phases; this point occurs at approximately 5 cm dilation [2]. In
nulliparous patients, the inflection point is often unclear and, if present, occurs at a
more advanced cervical dilation, typically at approximately 6 cm or more. In any
case, the inflection point is a retrospective finding.

● Second stage: The time from complete cervical dilation to fetal expulsion.

• Phases: Traditionally, the second stage does not have phases; however, when
pushing is delayed, some clinicians divide the second stage into a passive phase
(from complete cervical dilation to onset of active maternal expulsive efforts) and an
active phase (from beginning of active maternal expulsive efforts to expulsion of
the fetus) [3].
 ● Third stage: The time between fetal expulsion and placental expulsion.

● Fourth stage: Some clinicians identify a fourth stage of labor, which can be defined as
the first hour or two after placental expulsion when the uterus regains its tone and
begins the process of involution.

WHAT IS NORMAL LABOR PROGRESSION?

Background — In the 1950s, Emanuel Friedman described criteria for the normal progress
of labor (mean, 5th and 95th percentiles of cervical dilation over time) [4,5], and these criteria
were used for assessment and management of labor for decades. (See 'Friedman (historic)
observations' below.)

Since 2010, several studies have evaluated the normal progress of labor in thousands of
patients to establish contemporary criteria [6-8]. Most notably, Zhang et al studied data from
the Consortium of Safe Labor, which included 62,415 laboring patients at 19 hospitals in the
United States and provided the most robust contemporary data [6] (see 'Contemporary
observations' below). Importantly, these data are not describing a natural or unaided
process, rather, they describe time spent in labor resulting in a vaginal birth in contemporary
United States hospitals. Although patients included in the dataset entered labor
spontaneously, over 45 percent received oxytocin for labor augmentation, and nearly 75
percent received epidural analgesia.

Contemporary criteria are different from those described by Friedman: The active phase can
start at a more advanced cervical dilation, and dilation can be slower than originally
described and can still be normal (ie, associated with a high chance of vaginal birth and
normal newborn outcome) [9,10]. This change in the labor curve can be attributed to
changes in patient characteristics and obstetric practices. In contemporary cohorts, the
studied parturients tended to be racially diverse, older, and of higher weight. Oxytocin and
epidural were utilized more frequently while episiotomy and operative vaginal delivery were
less frequently performed [11]. Since studies in the past decade utilize contemporary and
robust data while Friedman's initial data were based on labors in only 500 nulliparous and
500 parous patients managed at a single institution, the Consortium of Safe Labor data
should inform evidence-based labor management [12].

The characteristics of normal labor progression remain unclear and controversial. Friedman
and Cohen have not accepted the revision of the classic labor curve, arguing that the shape
of the contemporary curve may have been influenced by selection biases, confounders, and
statistical methods [13,14].
The Labour Progression Study (LaPS) attempted to determine whether use of Friedman
criteria to diagnose normal versus abnormal labor progress resulted in better labor
outcomes than use of contemporary criteria [15]. In this multicenter cluster-randomized trial
in Norway comparing labor outcome in patients managed with a World Health Organization
(WHO) partogram based on Friedman data with those managed with a partogram based on
contemporary (Zhang) data, intrapartum cesarean birth rates and adverse outcomes were
similar for the two groups. Although the trial was well designed, the lack of generalizability
of the Norwegian study population is a major limitation. For example, the mean body mass
index (BMI; 23 kg/m2) and baseline cesarean rate (approximately 9 percent) were low
compared with the United States population (approximately 29 kg/m2 and 32 percent,
respectively [16,17]). Furthermore, routine use of a partogram has not been proven to be
beneficial (see 'Partogram' below). Interestingly, both study groups demonstrated a reduced
frequency of intrapartum cesarean birth during the study period when compared with the
frequency prior to the study, which supports the theory that an increased focus on labor
progress results in reduced rates of intrapartum cesarean birth.

Friedman (historic) observations — Emanuel Friedman conducted his now classic studies

defining the spectrum of normal labor by evaluating the course of labor of 500 nulliparous
and 500 parous patients admitted to the Sloane Hospital for Women in New York in the mid-
1950s [4,18,19]. Many more patients were studied in subsequent years to validate the
criteria. The norms established by these data, called the "Friedman curve" ( figure 1), were
widely accepted as the standard for assessment of normal labor progression for decades.

Key findings were:

● First stage

• The rate of cervical dilation is slow until approximately 3 to 4 cm (ie, latent phase), at
which time there is transition to more rapid dilation (ie, active phase).

• The statistical minimum rates (fifth percentile) of normal cervical dilation during the
active phase for nulliparous and parous patients were 1.2 and 1.5 cm/hour,
respectively.

• There is a deceleration phase in cervical dilation at approximately 9 cm.

● Second stage – The statistical maximum duration (95th percentile) for the second stage
also differs by parity:

• Nulliparous patients: 2.9 hours

• Parous patients: 1.1 hours
Contemporary observations — The Consortium on Safe Labor collected detailed
information from electronic medical records of >228,000 births from 19 hospitals across the
United States from 2002 to 2008. Zhang and colleagues evaluated a subset of these data,
which included information on 62,415 singleton pregnancies with spontaneous onset of
labor, cephalic vaginal birth (≥88 percent were spontaneous), and normal neonatal outcome,
to define normal labor progress [6].

Key findings were:

● First stage

• Once labor enters the active phase, cervical dilation is at least 1 to 2 cm/hour by
both historic and contemporary criteria. However, over 50 percent of patients in the
Consortium on Safe Labor database did not dilate by 1 to 2 cm/hour until they
reached 6 cm. Indeed, many nulliparous and parous patients who went on to have a
spontaneous vaginal birth took over six hours to dilate from 4 to 5 cm and over
three hours to dilate from 5 to 6 cm ( table 1), without an abrupt change in the
rate of cervical dilation indicating a clear transition from the latent to active phase
[6].

These findings suggest that the normal rate of cervical change between 4 and 6 cm
dilation can be much slower than that described by Friedman (see 'Friedman
(historic) observations' above) and that slow cervical dilation between 4 and 6 cm
reflects the shallow slope of the latent phase, not a protracted active phase
[7,20,21].

• Nulliparous and parous patients appeared to progress at a similar pace before 6 cm.
Beyond 6 cm dilation, the cervix dilated more rapidly in both nulliparous and parous
patients (although faster in parous than in nulliparous patients), suggesting that the
active phase begins by 6 cm in all patients and that slow cervical dilation (ie, less
than approximately 1 to 2 cm/hour) beyond this point is a deviation from the slope
of the contemporary normal labor curve and abnormal if it persists [6].

• A deceleration phase at the end of the first stage was not observed.

• The median (95th percentile) times for labor duration from 4 to 10 cm in nulliparous
and parous patients were 5.3 hours (16.4) and 3.8 hours (15.7), respectively [6]. In
contrast, Friedman reported the corresponding mean (95th percentile) durations in
nulliparous and parous patients were 4.6 hours (11.7) and 2.4 hours (5.2),
respectively [19]. The increase in labor duration in contemporary studies persisted
after adjustments were made for maternal and pregnancy characteristics [22],
suggesting that changes in labor practice patterns may be the primary reason for
 the increase. Although epidural use has increased dramatically since the 1960s,
increased use of epidural anesthesia does not fully account for the difference.
Further study is required.

● Second stage – The median (95th percentile) duration of the second stage was
( table 1) [6]:

• Nulliparous patients without epidural anesthesia: 0.6 hours (2.8)

Nulliparous patients with epidural anesthesia: 1.1 hours (3.6)

Parous patients without epidural anesthesia: 0.2 hours (1.3)

Parous patients with epidural anesthesia: 0.4 hours (2)

In addition to type of anesthesia, other characteristics such as diabetes, preeclampsia,

fetal size, chorioamnionitis [23], duration of the first stage [24], maternal height, and
station at complete dilation may also play a role in predicting the duration of the
second stage, but standards that account for these other characteristics are not
available [25]. The effect of induction is discussed below.

Normal progression in induced labors — The time to dilate 1 cm in latent phase (defined

as dilation <6 cm) is significantly longer in patients undergoing induction than in those in
spontaneous labor and can take many hours. However, the time to dilate 1 cm in the active
phase is similar to that of patients in spontaneous labor [26,27].

Latent phase — In a retrospective study of >1600 term pregnancies that reached the
second stage of labor, the median (95th percentile) times for each centimeter of dilation from
3 to 4, 4 to 5, and 5 to 6 cm (ie, latent phase) during induction were similar for nulliparous
and parous patients, and longer than for spontaneous labor ( table 2A-B) [26]:

Active phase and second stage — In contrast to a slower latent phase in induced
compared with spontaneous labors, the duration of the active phase (time to dilate from 6 to
10 cm) and second stage are similar in both induced and spontaneous labors ( table 2A-B)
[26-29].

ASSESSMENT OF LABOR PROGRESS

Digital examination — Cervical examinations to document cervical dilation, effacement,

and fetal station are usually performed:

● On admission
● At two- to four-hour intervals in the first stage
● Prior to administering analgesia/anesthesia
 ● When the parturient feels the urge to push (to determine whether the cervix is fully
dilated)
● At one- to two-hour intervals in the second stage (to evaluate descent)
● If fetal heart rate abnormalities occur (eg, to check for cord prolapse or a change in
station due to uterine rupture, to assess fetal position and station for possible vacuum-
or forceps-assisted vaginal delivery)

More frequent examinations are warranted when there is a concern about labor progress,
but they increase the risk of contaminating the intrauterine contents with vaginal flora. (See
"Intraamniotic infection (clinical chorioamnionitis)", section on 'Risk factors'.)

A limitation of digital examination is that it is imprecise, which is not a problem when

monitoring most labors, but is a concern when the clinician is trying to determine whether
cervical dilation and fetal descent are advancing too slowly or not at all. In a study that
evaluated the accuracy of digital measurement of cervical dilation with a position-tracking
system, when cervical dilation was >8 cm, the mean error of digital examination was
0.75±0.73 cm, and when cervical dilation was 6 to 8 cm, the mean error was 1.25±0.87 cm,
which is substantial [30]. However, a nondigital method for examining cervical dilation is not
available for clinical use.

Partogram — Results of cervical examinations may be documented on a partogram (also

called a partograph), which enables graphic comparison of the curve of the patient's cervical
dilation over time with the curve representing the expected lower limit of normal progress.
The partogram in the figure ( figure 2) is based on cervical dilation at admission and
shows the curves for the minimum rate of labor progress achieved by 95 percent of
nulliparous patients with singleton term pregnancies in spontaneous labor who had a
vaginal birth and normal neonatal outcome [6]. Right deviation from this curve suggests a
protraction or arrest disorder.

Although useful for visualizing labor progress, routine use of a partogram has not been
proven to significantly improve obstetric outcome, and no partogram has been proven to be
superior to others in comparative trials [31-33].

Ultrasound — Ultrasound cannot be used to measure cervical dilation without the use of

special equipment [30]. However, although not widely used clinically, it can document fetal
position and descent, the presence and extent of caput, and rotation (when performed
serially) in the second stage [34]. For assessing fetal position and station, it appears to be
more objective and reproducible than digital examination.

One technique is transperineal ultrasound (TPUS) measurement of the angle between the
symphysis pubis and the leading part of the fetal skull (called the angle of progression [AoP])
( figure 3) between contractions. Station is then determined from AoP using a formula [35]
or a table [36]. When the ultrasound is done at the beginning of the second stage, this
technique may be used to predict the likelihood of spontaneous vaginal birth. In a meta-
analysis (8 studies, 887 pregnancies), AoPs from 108 to 119 degrees yielded the highest
sensitivity (94 percent) and AoPs from 141 to 153 degrees yielded the highest specificity (82
percent) for predicting spontaneous vaginal birth [37].

Another approach is to measure the head to perineum distance (HPD) serially to assess
descent over time; however, station cannot be determined because the HPD measurement
does not account for the curvature of the birth canal [36]. In a study of nulliparous patients
in spontaneous labor at term, HPD of 30 mm and AoP 125 degrees each predicted birth
within three hours (95% CI 2.5-3.8 hours and 2.4-3.7 hours, respectively) in those who went
on to have a vaginal birth [38].

OVERVIEW OF PROTRACTION AND ARREST DISORDERS

Prevalence — Protraction and arrest disorders are common: Approximately 20 percent of all

labors ending in a live birth involve a protraction and/or arrest disorder [39]. The risk is
highest in nulliparous patients with term pregnancies. In a prospective Danish study, for
example, 37 percent of healthy term nulliparous patients experienced dystocia during labor
[40]. When only the second stage is considered, a systematic review found that the
prevalence in nulliparous patients with epidural anesthesia was 11.5 percent (two studies,
5350 participants) [41].

Reported prevalence varies among studies due to differences in the definitions used by
authors as well as differences among study populations (eg, gestational age range, personal
characteristics [eg, nulliparity and older maternal age have been associated with longer
labor]).

Clinical significance — Protraction or arrest of labor is the most common reason for

primary intrapartum cesarean birth. In one study including over 700 patients who had
unplanned intrapartum cesareans, 68 percent were due to lack of progress in labor [42].

Risk factors — Abnormal progress of spontaneously initiated labor may be related to

uterine factors, fetal factors, the bony pelvis, or a combination of these factors ( table 3)
[23]. A genetic component has been purported to account for 28 percent of the susceptibility
to protracted and difficult labor [43].

Selected risk factors for protraction and arrest are discussed below. Some risk factors are
more prominent during the first stage of labor and others primarily exert their effects in the
second stage.

Uterine factors
 Hypocontractile uterine activity — Hypocontractile uterine activity is the most
common risk factor for protraction and/or arrest disorders in the first stage of labor. Uterine
activity is either not sufficiently strong and/or frequent or not appropriately coordinated to
dilate the cervix and expel the fetus.

● Diagnosis (no pressure catheter) — Uterine activity can be monitored qualitatively by

palpation or with external tocodynamometry. The diagnosis of hypocontractile uterine
activity is based on the clinical perception that contractions are not strong on palpation
and/or infrequent (<3 or 4 contractions/10 minutes) and/or of short duration (<50
seconds) [44,45].

In most patients, this approach performs as well as the invasive approach using an
intrauterine pressure catheter (IUPC) for monitoring uterine activity [46]. Routine use of
IUPCs does not improve outcome [33,47]; however, selective use of an IUPC can be
helpful for assessing uterine activity when it is difficult to monitor contractions
externally, such as in patients with obesity. (See "Use of intrauterine pressure
catheters".)

● Diagnosis (using a pressure catheter) — Hypocontractile uterine activity can be

defined as less than 200 to 250 Montevideo units (MVUs). Use of an IUPC is necessary
to determine MVUs, which are calculated by subtracting the baseline uterine pressure
from the peak contraction pressure of each contraction in a 10-minute window and
adding the pressures generated by each contraction ( figure 4).

The threshold of 200 to 250 MVUs is based on the following two seminal studies [48,49]
and other data [44,50,51]:

• In a retrospective report of patients who had spontaneous vaginal births after

oxytocin induction [48]:

- 91 percent achieved contractile activity greater than 200 MVUs

- 40 percent reached 300 MVU

In patients who had spontaneous vaginal births after oxytocin augmentation:

- 77 percent achieved contractile activity greater than 200 MVUs

- 8 percent reached 300 MVUs

• In a study of patients with spontaneous initiation of labor, uterine activity averaged

approximately [49]:

- 100 MVUs in the early first stage of labor

- 175 MVUs in the advanced first stage
- 250 MVUs in the second stage
 Neuraxial anesthesia — The potential impact of neuraxial anesthesia on uterine
activity and fetal malposition has received a lot of attention as a possible source of
increasing rates of protracted labor, arrest, assisted vaginal birth, and cesarean birth.
However, randomized trials have not documented a substantial impact on the incidence of
protraction and arrest disorders.

In a meta-analysis of randomized trials comparing patients who received epidurals with

those who received opioids, both the first and second stages of labor were slightly longer in
the epidural group (first stage: mean difference [MD] 32.28 minutes, 95% CI 18.34-46.22;
second stage: MD 15.38 minutes, 95% CI 8.97-21.79); however, for the second-stage analysis,
heterogeneity was high and results were inconsistent (ie, in 3 of the 16 trials, the second
stage was 3, 9, and 12 minutes shorter in the epidural group) [52]. Oxytocin augmentation
trended higher in the epidural group (average relative risk [RR] 1.12, 95% CI 1.00-1.26) but
again, high heterogeneity warrants caution in interpretation. There was no clear difference
between the groups for cesarean birth because of dystocia (RR 0.93, 95% CI 0.79-1.11). (See
"Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on
the progress and outcome of labor'.)

Bandl's ring — An hourglass constriction ring of the uterus, called Bandl's ring, has
been estimated to occur in 1 in 5000 live births and is associated with obstructed labor in the
second stage [53-55]. The constriction forms between the upper contractile portion of the
uterus and the lower uterine segment. It is not clear if it is the cause or the result of the
associated labor abnormality. It may also become evident between birth of the first and
second twin.

● Diagnosis — The diagnosis is typically made at cesarean. At the time of laparotomy, a

transverse thickened muscular band can be observed separating the upper and lower
segment of the uterus. However, case reports have described predelivery diagnosis
using ultrasound [56,57]. Findings included thinning of the lower uterine segment, a
thick upper uterine segment, and a prominent ring that is unaffected by contractions
and is compressing the fetus.

Fetal and pelvic factors

Cephalopelvic disproportion — A disproportion in the size of the fetus relative to the

maternal pelvis can result in failure to progress in the second stage and has been termed
cephalopelvic disproportion (CPD). This may be due to fetal malposition (eg, extended or
asynclitic fetal head, occiput posterior [OP] or transverse position) or malpresentation
(mentum posterior, brow) (see 'Non-occiput anterior position' below) rather than a true
disparity between fetal size and maternal pelvic dimensions. These factors may result in
reduced force from the fetal head to the cervix, which has been associated with a protracted
labor course [58,59]. However, true CPD may occur if the fetus has a large surface anomaly
(eg, teratoma, conjoined twin), the maternal pelvic anatomy is not conducive to fetal
passage or is deformed (eg, after pelvic trauma), or the fetus is extremely large (although
vaginal births have been described in newborns weighing 13 to 17 pounds and more).

● Diagnosis — CPD is a subjective clinical assessment based on physical examination

and course of labor. It usually manifests as a prolonged second stage. It may also
manifest as failure of the head to engage. In a small prospective study of nulliparous
patients in active labor, a floating head (station ≥-3) at 7 cm dilation was predictive of
eventual cesarean birth in 100 percent of cases [60]. (See "Labor: Diagnosis and
management of a prolonged second stage", section on 'Diagnosis'.)

Antepartum, the clinician is generally unable to predict maternal pelvis/fetal size

discordance leading to arrest of labor requiring cesarean birth. Clinical and radiologic
assessments of the maternal pelvis and fetal size (ie, pelvimetry) are inexact and poorly
predict the course and outcome of labor [61,62], except at the extremes of pelvic
contraction or excessive fetal size. Radiographic pelvimetry is not recommended [62].

Non-occiput anterior position — The length of the second stage appears to correlate

with the degree of rotation away from occiput anterior (OA). Among nulliparous patients
under neuraxial anesthesia who began pushing at full dilation, the mean duration of the
second stage for OA, occiput transverse (OT), and OP positions was 2.2, 2.5, and 3 hours,
respectively, and the cesarean birth rates were 3.4, 6.9, and 15.2 percent, respectively [63].

● Diagnosis – The diagnosis can be made digitally, but ultrasound is more accurate [64].
Many fetuses actually enter labor in either OP or OT position and then undergo
spontaneous rotation of the fetal head during labor. Protraction and arrest disorders
associated with malposition occur when rotation to OA does not occur or is slow to
occur during labor. (See "Occiput posterior position" and "Occiput transverse position".)

MATERNAL AND NEWBORN OUTCOMES ASSOCIATED WITH ABNORMAL

LABOR PROGRESSION

● Maternal outcome – For the mother, first- and second-stage protraction disorders
have been associated with increased risks for the following outcomes in the affected
pregnancy [40,65-68]:

• Chorioamnionitis
• Assisted vaginal birth
• Obstetric anal sphincter injury
• Cesarean birth
• Postpartum hemorrhage,
 • Postpartum urinary retention
• Endometritis

A prolonged second stage may also impact the subsequent pregnancy. A second stage
≥180 minutes has been associated with a modest increase in risk of spontaneous
preterm birth in the next pregnancy in some studies [69]. However, the increase
appears to be largely driven by patients who undergo second-stage cesarean birth in
the antecedent pregnancy [70-72].

● Newborn outcome – For the neonate, a protracted first or second stage of labor has
been associated with increased risks for [66,67,73]:

• Admission to a neonatal intensive care unit.

• Respiratory distress syndrome.
• Confirmed or suspected sepsis.
• Birth asphyxia-related complications, which progressively increase with duration of
second stage (eg, from 0.42 percent for second stage <1 hour to 1.29 percent when
≥4 hours [adjusted relative risks 2.46, 95% CI 1.66-3.66] in one study [74]).

However, a prolonged second stage itself may not be the causal factor for these adverse
outcomes; factors such as persistent malposition or macrosomia may prolong the second
stage and independently increase maternal and/or neonatal morbidity. It remains unclear
whether performing a cesarean birth earlier rather than later in the second stage of labor
would reduce the risk of adverse outcomes compared with continued labor. In a small trial of
patients with a prolonged second stage, extending the duration of the second stage for at
least one hour versus expedited operative delivery did not increase the rates of maternal
and neonatal complications, but the trial was underpowered to detect small differences in
these outcomes [75].

DIAGNOSIS AND MANAGEMENT OF FIRST- AND SECOND-STAGE LABOR

ABNORMALITES

● In the latent phase of the first stage, there are no uniformly accepted contemporary
criteria for normal or abnormal duration. Intervention for a "prolonged" latent phase is
based on factors such as how well the patient is coping with the physical and emotional
challenges of this phase. (See "Labor: Diagnosis and management of the latent phase".)

● In the active phase of the first stage, the diagnosis of protraction and arrest disorders
is independent of parity and based on deviation (ie, >95th percentile) from
contemporary norms. (See "Labor: Diagnosis and management of an abnormal first
stage".)
 ● The diagnosis of a prolonged second stage (ie, minimal or no fetal descent or rotation
over time) is based on parity, duration of pushing, and presence/absence of neuraxial
anesthesia. (See "Labor: Diagnosis and management of a prolonged second stage".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Labor".)

SUMMARY AND RECOMMENDATIONS

● Stages and phases of labor – The first stage of labor lasts until full cervical dilation,
the second ends with fetal expulsion, and the third ends with placental expulsion; some
clinicians include a fourth stage for the early hours after placental expulsion. The first
stage has a latent and an active phase; the active phase begins by 6 cm dilation in both
nulliparous and parous patients. (See 'Definitions for the stages and phases of labor'
above and 'Contemporary observations' above.)

● Normal labor progress of spontaneous labor

• Labor curves ( figure 5) and norms ( table 1) based on contemporary data from
the Consortium on Safe Labor have become widely used and are different from
those cited by Friedman, who used data from the 1950s. Contemporary data
suggest that the normal rate of cervical change between 3 and 6 cm dilation is
much slower than described by Friedman, thus patients who are slowly dilating at
this point in labor may still be in the latent phase. However, by 6 cm, all patients in
normal labor should be in the active phase. (See 'Contemporary observations'
above.)

• In both contemporary and historic labor curves, the progress of the normal first and
second stages of labor is different in nulliparous versus parous patients
( figure 5). (See 'Contemporary observations' above and 'Friedman (historic)
observations' above.)

● Progress in induced labors – The normal duration of the latent phase tends to be
longer in induced than spontaneous labors, but the active phase and second stage
have similar durations whether labor is spontaneous or induced ( table 2A-B). (See
'Normal progression in induced labors' above.)

● Prevalence and risk factors for labor abnormalities – Approximately 20 percent of all
labors ending in a live birth involve a protraction and/or arrest disorder. Risk factors for
 labor abnormalities may be related to uterine, fetal, or pelvic factors, or a combination
of factors ( table 3). (See 'Risk factors' above.)

● Consequences of labor abnormalities – A prolonged first or second stage of labor is

associated with an increased risk for a variety of adverse maternal and newborn
outcomes, including infection, operative birth and its sequelae, and admission to a
neonatal intensive care unit. (See 'Maternal and newborn outcomes associated with
abnormal labor progression' above.)

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Topic 4464 Version 109.0
GRAPHICS

Friedman labor curve

First stage = A + B + C + D, where A = latent phase, B = acceleration phase, C

= phase of maximum slope, and D = deceleration phase.

Second stage = E.

Data from: Friedman EA. Labor: Clinical evaluation and management, 2nd ed, Appleton-
Century-Crofts, New York 1978.

Graphic 53413 Version 4.0

Contemporary estimates of median and 95th percentile in hours by parity

Parity 0 Parity 1
  Median number of hours
Median number of hours

(95th percentile) (95th percentile)

Change in cervix

From 4 to 5 cm 1.3 (6.4) 1.4 (7.3)

From 5 to 6 cm 0.8 (3.2) 0.8 (3.4)

From 6 to 7 cm 0.6 (2.2) 0.5 (1.9)

From 7 to 8 cm 0.5 (1.6) 0.4 (1.3)

From 8 to 9 cm 0.5 (1.4) 0.3 (1.0)

From 9 to 10 cm 0.5 (1.8) 0.3 (0.9)

Duration of second stage

Second stage with epidural 1.1 (3.6) 0.4 (2.0)

analgesia

Second stage without 0.6 (2.8) 0.2 (1.3)

epidural analgesia

Note the 95th percentile for duration of time to dilate from 4 to 6 cm is almost 10 hours in
nulliparous women.

Data from: Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal
outcomes. Obstet Gynecol 2010; 116:1281.

Graphic 69170 Version 16.0

Time in hours for each centimeter of cervical dilation in nulliparous
patients

Induction of Augmented Spontaneous

Cervical
labor
p* labor
p* labor

dilation (cm)
(n=732) (n=688) (n=572)

4 to 10 5.5 (1.8, 16.8) <0.01 5.4 (1.8, 16.8) <0.01 3.8 (1.2, 11.8)

3 to 4 1.4 (0.2, 8.1) <0.01 1.2 (0.2, 6.8) <0.01 0.4 (0.1, 2.3)

4 to 5 1.3 (0.2, 6.8) <0.01 1.4 (0.3, 7.6) <0.01 0.5 (0.1, 2.7)

5 to 6 0.6 (0.1, 4.3) 0.02 0.7 (0.1, 4.9) <0.01 0.4 (0.06, 2.7)

6 to 7 0.4 (0.05, 2.8) 0.05 0.5 (0.06, 3.9) <0.01 0.3 (0.03, 2.1)

7 to 8 0.2 (0.03, 1.5) 0.93 0.3 (0.05, 2.2) 0.01 0.3 (0.04, 1.7)

8 to 9 0.2 (0.03, 1.3) 0.80 0.3 (0.05, 2.0) <0.01 0.2 (0.03, 1.3)

9 to 10 0.3 (0.04, 1.9) 0.13 0.3 (0.05, 2.4) <0.01 0.3 (0.04, 1.8)

Data presented in hours as median (5th percentile, 95th percentile) unless otherwise specified.
The reference group was spontaneous labor.

* Adjusted for race, body mass index greater than 30 kg/m2 , birth weight greater than 4000 g,
and Bishop score higher than 5 at admission.

From: Harper LM, Caughey AB, Odibo AO, et al. Normal progress of induced labor. Obstet Gynecol 2012; 119:1113. DOI:
10.1097/AOG.0b013e318253d7aa. Copyright © 2012 American College of Obstetricians and Gynecologists. Reproduced
with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.

Graphic 132751 Version 1.0

Time in hours for each centimeter of cervical dilation in parous patients

Induction of Augmentation Spontaneous

Cervical
labor
P* of labor
P* labor

dilation (cm)
(n = 915) (n = 1032) (n = 1449)

4-10 4.4 (1.2, 16.2) <0.01 4.7 (1.3, 17.5) <0.01 2.4 (0.6, 8.8)

3-4 1.5 (0.2, 10.2) <0.01 1.1 (0.2, 7.5) <0.01 0.3 (0.05, 2.3)

4-5 1.2 (0.2, 7.9) <0.01 1.3 (0.2, 8.2) <0.01 0.3 (0.04, 1.9)

5-6 0.5 (0.1, 4.2) <0.01 0.8 (0.1, 6.0) <0.01 0.2 (0.03, 1.7)

6-7 0.3 (0.03, 1.8) 0.03 0.4 (0.06, 3.2) <0.01 0.2 (0.03, 1.6)

7-8 0.1 (0.02, 1.0) 0.72 0.3 (0.04, 1.7) <0.01 0.2 (0.03, 1.3)

8-9 0.1 (0.02, 0.8) 0.50 0.2 (0.03, 1.3) <0.01 0.2 (0.02, 1.0)

9-10 0.1 (0.02, 0.8) 0.50 0.2 (0.03, 1.1) <0.01 0.1 (0.02, 0.8)

Data presented in hours as median (5th percentile, 95th percentile) unless otherwise specified.
The reference group was spontaneous labor.

* Adjusted for race, body mass index greater than 30 kg/m2 , birth weight greater than 4000 g,
and Bishop score higher than 5 at admission.

From: Harper LM, Caughey AB, Odibo AO, et al. Normal progress of induced labor. Obstet Gynecol 2012; 119:1113. DOI:
10.1097/AOG.0b013e318253d7aa. Copyright © 2012 American College of Obstetricians and Gynecologists. Reproduced
with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.

Graphic 132752 Version 3.0

Contemporary estimates of labor duration by dilation at
admission

The 95th percentiles of cumulative duration of labor from admission among

singleton term nulliparous women with spontaneous onset of labor, vaginal
delivery, and normal neonatal outcomes. Colors represent cervical dilation when
women were admitted to the labor unit: green (5 cm), yellow (4 cm), blue (3 cm),
red (2 cm).

Data from: Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with
normal neonatal outcomes. Obstet Gynecol 2010; 116:1281.

Graphic 89191 Version 4.0

Angle of progression

The angle of progression is the angle between a straight line drawn along the
longitudinal axis of the pubic bone and a line drawn from the inferior edge of
the pubic bone to the leading edge of the fetal cranium.

Data from: Kalache KD, Dückelmann AM, Michaelis SA, et al. Transperineal ultrasound imaging in
prolonged second stage of labor with occipitoanterior presenting fetuses: how well does the
'angle of progression' predict the mode of delivery? Ultrasound Obstet Gynecol 2009; 33:326.

Graphic 110927 Version 2.0

Factors that may be associated with protracted labor

Uterine factors (hypocontractile uterine activity)

Older maternal age

Uterine abnormality 

Maternal obesity

Neuraxial anesthesia

Bandl's ring 

Nulliparity

Tocolytics, uterine relaxants

Infection

Pelvic factors

Pelvic contraction (eg, thin subpubic arch, prominent sacrum)

Short stature (less than 150 cm [4 feet 11 inches])

High station at full dilation

Fetal factors

 Fetal anomaly resulting in cephalopelvic dystocia 

 Non-occiput anterior position

 Large for gestational/macrosomia

Graphic 66586 Version 7.0

Cardiotocography showing calculation of Montevideo units

Montevideo units are calculated by subtracting the baseline uterine pressure from the peak
contraction pressure of each contraction (arrows) in a 10-minute window and adding the
pressures generated by each contraction.

FHR: fetal heart rate; bpm: beats per minute; mmHg: millimeters of mercury; kPa:
kilopascals; UA: uterine activity.

Graphic 57354 Version 6.0

Contemporary labor curves by parity

Average labor curves by parity in singleton term pregnancies with

spontaneous onset of labor, vaginal delivery, and normal neonatal outcomes.
Note that for parous women, the inflection point for acceleration of cervical
dilation is at approximately 6 cm and that there is no clear inflection point for
nulliparous women.

Data from: Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor
with normal neonatal outcomes. Obstet Gynecol 2010; 116:1281.

Graphic 89190 Version 6.0

Contributor Disclosures
Robert M Ehsanipoor, MD No relevant financial relationship(s) with ineligible companies to
disclose. Andrew J Satin, MD, FACOG No relevant financial relationship(s) with ineligible companies to
disclose. Vincenzo Berghella, MD Consultant/Advisory Boards: ProtocolNow [Clinical guidelines].
All of
the relevant financial relationships listed have been mitigated. Vanessa A Barss, MD, FACOG No
relevant financial relationship(s) with ineligible companies to disclose.

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